Developing Assessments and Interventions for Phantom Limb Pain in Veterans with Amputations

幻肢痛（PLP）严重损害康复结果和社区参与， 下肢截肢的退伍军人。PLP是一种神经性疼痛，其中损伤或疾病 影响神经系统导致无法控制的疼痛先前的神经影像学研究表明，大脑- 截肢后的基础变化有助于PLP。先前记录的变更包括 截肢的感觉表征降低（即感觉地图变化）， 结构之间的连接。随着神经成像技术的进步，我们现在可以研究 下肢截肢者的变化，从而为新的康复设计提供信息 干预措施。本课题的目的是研究下肢运动后脑组织的变化 截肢以确定PLP的神经相关性。 越来越多的证据支持神经调节作为非药物治疗的有效性。 包括PLP在内的慢性疼痛治疗技术。神经调节是一系列利用电刺激的技术， 输入以调节大脑区域的活动，并且包括诸如非侵入性 脑刺激（NIBS）。通过将NIBS与已知有效的现有康复技术相结合， 对于一些PLP患者，我们可以针对大脑的变化来减少PLP。虽然有初步 PLP的神经成像和神经调节证据，这在退伍军人人群中尚未研究。 通过退伍军人管理局（VA）公司数据仓库，使用信息学和 计算基础设施（芬奇）国家数据库，我们了解到，VA医疗保健系统关心 36,000名截肢的退伍军人，其中81%的退伍军人因疼痛而开阿片类药物。 截肢后护理的复杂性是巨大的，特别是考虑到我们的退伍军人有额外的合作， 病态这项工作的长期目标是研究联合的，非药理学的 在CDA-2提案中，将通过临床试验对退伍军人PLP进行康复干预。 然而，在我们调查联合干预的效果之前，我们必须首先调查 退伍军人人群中PLP的神经相关因素。 该提案的目的涉及16名退伍军人（18岁以上）单侧经胫骨截肢（8 有8名退伍军人没有PLP）。首先，退伍军人将被要求完成疼痛病人- 报告的结果包括调查疼痛如何干扰日常生活和疼痛的具体情况， （频率、持续时间、疼痛描述），结合关于假体佩戴的调查问题 模式.第二，退伍军人将参加磁共振中心的神经成像 研究（CMRR）在我们的学术分支机构，明尼苏达大学。成像序列将 包括两种形式功能性磁共振成像（fMRI）。第一个功能磁共振成像序列是静止的- 状态来评估休息时大脑活动的连通性。第二个功能磁共振成像序列是一个感觉序列， 任务使用脑电驱动的感觉刺激来评估大脑如何解释感觉 残肢和对侧肢体的信息。 总而言之，CDA-1提案将引导我们开发新的PLP干预措施。我们预计我们的干预 将更加有效，因为干预的设计是由神经成像结果提供信息的。与此 初步数据，我们将准备设计和测试组合新的康复干预措施， 减少退伍军人中的PLP。VA医疗保健系统可以引领创新，有效 治疗PLP的方法，在未来，非药物PLP干预可以个性化 根据他们的临床资料给老兵

Phantom limb pain (PLP) significantly impairs rehabilitation outcomes and community participation for Veterans with lower limb amputations. PLP is a form of neuropathic pain, where damage or disease affects the nervous system causing uncontrolled pain. Prior neuroimaging research suggests that brain- based changes following amputation contribute to PLP. Changes previously documented include decreased sensory representation of the amputated limb (i.e. sensory map changes) and decreased connectivity between structures. With advancements in neuroimaging, we can now study brain-based changes in persons with lower limb amputations thus informing the design of novel rehabilitation interventions. The objective of this project is to investigate brain-based changes following lower limb amputation to identify neurocorrelates of PLP. There is growing evidence supporting the efficacy of neuromodulation as a non-pharmacological technique for chronic pain including PLP. Neuromodulation is a family of techniques that utilize electrical input to modulate the activity of a region of the brain and includes techniques such as non-invasive brain stimulation (NIBS). By pairing NIBS with existing rehabilitation techniques known to be effective for some with PLP, we can target brain-based changes to reduce PLP. Although there is preliminary evidence of neuroimaging and neuromodulation for PLP, this is unstudied in the Veteran population. Through the Veteran’s Administration (VA) Corporate data warehouse using the Informatics and Computing Infrastructure (VINCI) national database, we learned that the VA Health Care System cares for 36,000 Veterans with amputations where 81% of those Veterans have prescribed opioids for pain. The complexities of post-amputation care are great especially given our Veterans have additional co- morbidities. The long-term goal of this work is to investigate combined, non-pharmacological rehabilitation intervention for PLP in Veterans to be tested with a clinical trial in a CDA-2 proposal. However, before we can investigate the effect of a combined intervention, we must first investigate neurocorrelates of PLP in the Veteran population. The aim of this proposal involves 16 Veterans (ages 18+) with unilateral transtibial amputation (8 Veterans with and 8 Veterans without PLP). First, the Veterans will be asked to complete pain patient- reported outcomes including surveys that examine how pain interferes with daily life and pain-specifics (frequency, duration, description of pain), in combination with survey questions on prosthesis wearing patterns. Second, the Veterans will participate in neuroimaging at the Center for Magnetic Resonance Research (CMRR) at our academic affiliate, the University of Minnesota. Imaging sequences will include two forms of functional magnetic resonance imaging (fMRI). The first fMRI sequence is resting- state to evaluate the connectivity of the brain activity at rest. The second fMRI sequence is a sensory task using pneumatic-driven sensory stimulation to evaluate how the brain interprets sensory information for the residual limb and contralateral limb. Altogether, this CDA-1 proposal will lead us to novel PLP interventions. We anticipate our interventions will be more effective as the design of intervention is informed by neuroimaging results. With this preliminary data, we will be prepared to design and test combined novel rehabilitation interventions for the reduction of PLP in Veterans. The VA Health Care System can lead the way in innovative, effective methods to treat PLP where in the future, non-pharmacological, PLP interventions can be personalized to the Veteran based on their clinical profile.